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Many hospitals don’t do enough to support health workers after an adverse event

The boy stopped breathing. That morning, he had been admitted with what seemed like a seizure to the emergency room at IWK Health Centre in Halifax. He had been given drugs to stop the seizure.

Katrina Hurley, an emergency doctor just starting her night shift and taking over the case, thought the boy was over-sedated from the drugs, and she told this to his parents. As her team resuscitated the child, the parents yelled “You did this!” at Hurley.

The child who suffered multiple, severe health problems had a shunt that was draining fluid from his brain to his abdomen. In reality, that shunt had become blocked. It wasn’t the drugs, but the excess fluid in the brain that was causing his symptoms. He died two days later.

The investigation into his death concluded that even if the shunt failure had been recognized earlier by medical staff, the boy would likely have died anyway. “It wasn’t that we could have saved him but we could have managed it differently,” says Hurley. The boy’s parent’s would have at least known that everything possible was done to save their son.

When Dr. Hurley crawled into bed after that night shift, her mind raced with thoughts of everything she could have done differently. “I was exhausted, because it had been an exhausting night, but sleep couldn’t come to me,” she says. “Every time you close your eyes, you picture the situation.”

Albert Wu, a doctor who has been studying medical errors for more than 15 years, coined the term “second victim” in 2000 to describe health workers who suffer psychologically after an adverse event. In some cases, the health worker may have made an error that contributed to harming a patient; in other cases, a poor outcome or death was simply unexpected and therefore traumatizing.

Currently, most hospitals don’t appear to be doing enough to support second victims. That’s a problem for many reasons, chief among them that “health care is supposed to be designed to take care of people who are suffering and these people are suffering,” says Stephen Pratt, an anesthesiologist and chief of the division of quality and safety in anesthesia at the Beth Israel Deaconess Medical Center in Boston. From a health care system perspective, supporting second victims may reduce health worker turnover and lead to better patient care.

What is a second victim?

The term second victim is problematic, says Pratt. Health workers don’t want to call themselves victims when patients and their families have been harmed. And in the case of medical error, “you don’t feel like a victim. You feel like a perpetrator,” he says. Due to the lack of another accepted term, however, we will use the term.

Research into the phenomenon is still in its infancy, but the few studies available suggest anywhere from 10% to 40% of health workers will experience trauma following an adverse event.

Second victims can experience guilt, anxiety, depression, self-doubt, reduced job satisfaction and frustration. They may find themselves reliving the event days, weeks or months later. The Canadian Medical Protective Association writes that in the case of possible errors, “physicians often harbour visions of disastrous personal consequences, such as the loss of reputation…or revocation of their medical licence.” In severe cases, the person can be diagnosed with post-traumatic stress disorder.

A significant number of second victims rely on their own support network and coping mechanisms to recover after an adverse event, says Hanan Edrees, a patient safety coach at Johns Hopkins University. In some extremes, however, health workers may leave their job, turn to alcohol or other substances, or even commit suicide. In a survey of almost 8,000 American surgeons, those who believed they had made a serious medical error in the previous three months were three times as likely to report they’d contemplated suicide in the previous year. In 2011, Kimberly Hiatt, an ICU nurse in Seattle, committed suicide after she was fired for accidentally giving an infant a ten-fold overdose of calcium, which likely caused the infant’s death.

Anecdotal evidence suggests unsupported health workers may also change their place of work or leave their career altogether due to the psychological stress of a medical incident. Bruce MacLeod, an emergency physician and medical advisor for quality and patient safety at Alberta Health Services, investigated an incident involving a child’s death 20 years ago. No one person “really did anything wrong” and system changes were made as a result. However, three years later, 80% of the “well-trained, caring, experienced nurses” in the large emergency department had moved on, either to another hospital or another career altogether. “In the exit interviews, many people mentioned the stress of this particular case,” says McLeod, who says before the event, staffing had been very stable.

When health workers are supported through adverse events, however, they can provide valuable input in how to prevent errors in the future, says MacLeod.

Most health systems don’t adequately support second victims

Shabnum Durrani, director of public affairs for the Ontario Hospital Association, was only aware of two Ontario hospitals that have specific supports in place for second victims (on top of the Employee Assistance Programs that offer counseling to staff for any mental health issue).

Toronto East General Hospital launched a second victim support program in its emergency department in late 2012. After an “unexpected traumatic clinical event,” a health worker or his or her manager can reach out to the ED Care and Support team, which include nurses, a social worker, a patient relations representative and chaplain. A member of this team will provide one-on-one counseling immediately after the event and “at regular intervals afterward,” writes Sharon Navarro, senior consultant in communications at the hospital.

Mount Sinai Hospital in Toronto is providing a three-hour education session to all staff this year on coping with the acute “vicarious trauma” and the “compassion fatigue,” or numbness that can result over time from such encounters, explains Melissa Barton, director of occupational health, wellness and safety at Mount Sinai Hospital. Following major incidents such as a death that is particularly difficult for a team, psychiatrists from the hospital are dispatched to provide group counseling.

Alberta Health Services is taking steps toward developing a province-wide second victim strategy. Over the last year, the organization that oversees health care for the province has established a team of experts to “review the literature and find out what is the best science, what is being done in other organizations, and put together our vision of what the perfect scenario would be,” explains MacLeod.

Without such training and support programs, the culture of medicine can amplify the psychological trauma of a health worker. Both doctors and nurses tend to expect perfection and assign individual responsibility for errors, rather than focus on system responsibility, explains Pratt. That’s partly because if they believe they are individually in control, they believe they can prevent bad things from happening to their patients, he says. In reality, adverse events are “almost never caused by a bad doctor or a bad nurse,” says Wu. “It’s the way that systems are designed so that if you make a slip or you are human in some way, all the other holes were lined up too and the bullet gets through.”

A culture that wants to assign blame is ripe for gossip. In Hurley’s case, the news of the misdiagnosis spread rapidly. “All the nurses were talking about it, and so many stories got told, some of it by people who weren’t actually there,” she says. Days after the boy’s death, Hurley was reviewing another case with a learner, when a nurse asked, “What went wrong with that case?” Hurley was overcome with sadness, at a time when she needed to focus on another patient, and maintain her composure in front of her trainee. “I didn’t want to have an emotional breakdown in front of everybody,” she says.

No one at the hospital reached out to Hurley to see how she was coping but she says hospital managers are currently “discussing” how to better support health workers experiencing similar self-doubt and distress.

Best practices for supporting health workers after an adverse event

No studies have been conducted to robustly evaluate interventions for health workers psychologically affected by medical events so “there is no consensus” on the ideal way to support health workers, says Edrees.

The first peer support program for health workers affected by adverse patient events was launched in 2007 at the University of Missouri Health Care (UMHC). As the director of the Center for Health Services and Outcomes Research at the John’s Hopkins Bloomberg School of Public Health, Wu helped implement a similar program at John’s Hopkins Hospital in 2012.

At these second victim programs, as well as at the second victim program for emergency department staff at Toronto East General Hospital, counsellors aim to immediately administer what’s known as “psychological first aid.” It’s an approach routinely used for disaster responders, firefighters, and children and adults following traumatic events. “Listening is about 90% of it,” says Wu. The approach also involves calming and reassuring the individual, and discussing what coping mechanisms have worked in the past for that person.

Pratt argues, however, that simply having the right kind of counselling available isn’t enough. Educational campaigns need to make health workers aware of the second victim phenomenon, how it affects people and how to identify it. Hospital managers also need to work to combat the stigma around seeking psychological help. This stigma is especially acute for health workers, who are supposed to be the strong caregivers to their patients. “If even taking that business card for counselling in front of your colleagues can feel too shameful, the program won’t work,” explains Pratt.

Moving forward

The Canadian Patient Safety Institute (CPSI) is in the process of integrating information about second victims into its training for quality and safety personnel in hospitals across the country, says Chris Power, CEO of the organization. The organization recently hosted a national conversation on supporting second victims.

Much work remains, however. Formal second victim programs, involving a needs assessment, leadership buy-in, system-wide education and awareness campaigns, can take four years to develop, according to Susan Donnell Scott, who developed UMHC’s program. Medically Induced Trauma Support Services has created several toolkits to guide health care organizations through the process.

In the mean time, health care organizations can raise awareness of second victims in communications to staff and remind staff of psychological help already available to them, suggests Pratt.

Whatever systems are put in place, Power underlines the importance of following up with health workers after an adverse event. Initially, some health workers prefer to “normalize” the situation by focusing on work, she says, and people might only recognize they need help days or weeks later. “These things don’t go away. When you’ve made an error, you think about it for a long time.”

Enter the debate: reply to an existing comment

11 comments

sober second thoughtJune 18th, 2015 at 8:21 am

good article documenting an issue that’s received little to no attention in the public consciousness. its bad enough that incidents leave providers with these experiences (most of us in other jobs would not put up with this from our “customers or clients”). Its’ even worse when hospital managers don’t do enough to combat the stigma with seeking support. %featured%Most reporting or debriefing has a decidedly self-preservation stance from management and the health care facility, in order to mitigate risk around malpractice, negligence, etc.%featured%

We have been asking for this in the Red Deer AB ICU for the past 20 years. I even had someone speak on “Vicarious Trauma” at a Team Building day. We have asked for a Psychologist on staff to help us deal with critical incidents immediately but all to no effect. In fact we now haven’t had Team Building in the past 6-8 years. When you approach our boss concerning having debriefings, she states they aren’t to be done immediately anymore. However this also means they are never done and followed up on. The only debriefing/support for the caregivers I am aware of I organized myself(as the Charge Nurse) after a particularly traumatic day where I’m not sure myself or the staff member dealing with the patient and family would have been safe to drive ourselves home without. I called upon our Chaplain to help with it.
This would definitely decrease the PTSD and Caregiver Fatigue that is so prevalent in critical care areas of the hospital as well as first responders.

Thanks for sharing this important and rarely voiced perspective. It resonates loudly.

%featured%Working in an environment with supportive colleagues and making it routine to discuss difficult cases and errors is essential. It’s too bad that one realizes this only after the need arises! Hopefully, the tools and conversations mentioned above will become commonplace in our life times.%featured%

I think we all have to change. %featured%We all share the belief that physicians (and other health care providers) have to be perfect. This is the way our patients think, and this is the ways we health care providers think too, or accept to start thinking, as this is the expectation society has of health care providers.%featured% Making a mistake would mean we as health care providers are flawed and we should be ashamed when we make those mistakes. Admitting that you were involved in a mistake would then equate to assuming you did not meet what society expects of you; being perfect and never committing mistake:

“Shame on you! You should know better!”

Therefore, it is no surprise that hospitals do not support enough health care providers involved in medical errors. Medical errors are very costly in emotional terms to patients, their loved ones and health care providers.

There is another problem: as admitting one’s limitation is not well accept in health care, we fail to develop ways to compensate for our normal human limitations. Instead of accepting that it is impossible to remember the thousands of different medication interactions that exist, and utilizing electronic safeguards to check for medication interactions; we health care providers underutilize such resources. Why? Utilizing such resources could be seen as further evidence that we as health care providers are not meeting the societal expectation of knowing everything and being perfect. The consequence of that? More mistakes occur, more patients are harmed and more health care providers feel guilty. This is a terrible cycle that needs to be broken.

We all have to change. Firstly, we, patients and health care providers, have to accept that we are human and human beings tend to make mistakes. Secondly, we have to accept that the most important thing is having safe treatments; patients and health care providers have to be allied in this process. Our patients can be our best allies in the process of transforming health care. Once we all change, we all will win.

%featured%You might be interested in looking at Schwartz Rounds – started in the US – now in over 45 sites and have moved to the UK with the Point of Care Foundation. (www.pointofcarefoundation.org.uk). Provides a safe and non threatening environment for staff to grieve, be upset, be angry and be supported.%featured% Only Canadian org I know that has been accredited (you have to apply) is Holland Bloorview Kids Rehab. They held their first rounds a few weeks ago. Point of Care Foundation has published on impact etc.

%featured%We can no longer ignore that as healthcare professionals we are human and fallible. Providing support when mistakes happen is an organizational and professional responsibility.%featured% Together we will figure out the best way to do this within a Canadian context.

I am a 4rth year B. Sc. nursing student at Trent University. I am writing to share my perspective on your recent article “Many hospitals don’t do enough to support health workers after an adverse event” from healthydebate.ca published on June 18th, 2015.

The above article is of great importance as the “second victim” phenomenon is worrisome to future nurses like myself. Oftentimes, healthcare providers falsely blame themselves for systemic errors. Health care providers feel emotionally traumatized when they encounter adverse patient events. Often nothing can be done to stop a tragedy. For instance, an ailing child’s death had occurred due to shunt failure, yet parents falsely assume the professionals could have done something differently to change the outcome. Our society thinks that Drs. and other health care providers’ have to be perfect in every action. However, this expectation creates pressure on healthcare providers, which could be counterproductive. Sometimes, a person’s stress reaction after an adverse event can be more difficult and may last for few days, weeks, months or longer. Therefore, it is necessary to provide them with an opportunity to discuss the details of the event or share how this has affected them personally or professionally.

To assist the “second victim” counseling should be provided to all health care providers. This is a great start, however, awareness outside the health care community is also necessary. %featured%This can be accomplished through a viral social media campaign with videos and interactive information detailing the facts behind how often health care providers are blamed for illnesses and deaths that may simply out of their control. This is crucial so that people can begin to comprehend that stressing out health care providers will only increase the potential for them to seek careers outside of healthcare, leaving more patients without resources.%featured% Society needs to accept that we all are human, and inadvertent errors do happen, and as such we all must be supportive to each other, thereby preventing any chances of further anxiety, fear of persecution and victimization. Healthcare errors do happen but it must not be deliberate, by ignorance, neglect or due to haste.

Going through residency training, I am seeing this very frequently. What is often overlooked is that every resident/nurse/attending is juggling a multitude of patients at a single time. For example, a first year resident covers approximately 50 patients on the wards while on call (which is 28 hrs straight often without a break), as well as admitting patients in the emergency department. You may have multiple patients deteriorating at the same time and your job is to triage and address the sickest patient first. However, you often cover patients you have never met before, therefore, you triage based on very limited history you were provided with during hand over. It takes time to figure out what is wrong with a patient…none of the information is at your finger tips majority of the time due to lack of document sharing between all hospitals/illegible hand writing, etc. You do your absolute best, but we will all face diagnostic error that has harmful consequences to our patients due to personal and system flaws at least once or twice in our career, and in reality that is probably an underestimate. The hope is that we do not start pointing fingers, but try to figure out a way to have a safer system.

As a fourth year nursing student, I have been taught that it is important to report errors incidences such as medication errors and near misses so that the facility can learn from these errors and learn from them. I have been taught that it is important to be honest and open about errors, and that punitive measures are unlikely to occur if the event has been reported. A study by Statistics Canada found that 19% of RNs made medication errors “occasionally” or “frequently” over the course of a year. His study found that nurses with low support from their co-workers were significantly more likely to have made a medication error, while there was no link between medication errors and supervisor support. This shows how important it is for nurses to be supportive of their peers, and work together as a team. It is important to accept that nurses are human and that errors can happen as a result of a variety of factors. When another nurse makes an error, it is important to be supportive of them, rather than judge them.

This article outlines programs which certain hospitals have put into place to support health care workers who are involved in an adverse event. While it is important for more hospitals to implement these types of programs, they must also consider that there is stigma around asking for this type of help, and it is important to attempt to decrease this stigma. %featured%Creating programs that reach out to workers involved in adverse events would be helpful in achieving this, however, as health care professionals, it is important that we recognize when these events occur, and provide support to our peers.%featured% Providing support rather than judging others for their errors will help create a healthier environment.

I am late to this conversation but in summary I can tell you that all the comments that have been made are valid and in need of a solution!
I was most fortunate to have discovered the work of Dr. Peter Pronovost at Johns Hopkins. He is the author: Safe Patients Smart Hospitals, Penguin, 2010. He, along with the Armstrong Safety Institute also set up a Coursera course (online platform) on The Science of Patient Safety which I took in 2013. It not only changes the way you think, you’ll see all the patients safety gaps everywhere you go, and, have the opportunity to remedy the situation because the course of study is designed to overcome the problems that currently exist.
The bigger problem, is getting everyone onside, and this seems to be, because most don’t know the course exists, and when they’re made aware, it doesn’t seem to matter to the bigger group who’ve had no awareness or exposure to such a well developed douse of study.
I think there needs to be better regulation beginning with a mandate that all hospital administration and staff have to take this course. So should engaged patents who’ve got concerns!
I have one chapter in my upcoming book that covers his work extensively and sent my work to him at his request and he liked the way I’d integrated the work his team has done.
I can’t give enough praise and recommendation for his work. I hope this helps. If you want more information, please contact me at: listeningtothepatient@gmail.com

I totally agree that we become the second victim. I recall one situation in the ICU when I worked the night shift. I had a 21 year old with pulmonary hypertension. She was awaiting heart lung transplant. The physicians on day shift had started an experiment with calcium channel blockers but called it off prior to the night shift. However, somehow this was not communicated to the poor resident who was to reside and to the night nurse either. Cardiac outputs were done hourly and a calcium channel blocker was given to her po hourly. I did not like the situation and relayed my fear that she was going to crash! The resident told me to continue the treatment. In the monrning she did crash and she was rushed to the OR where manual massage of her heart was done along with calcum being injected directly into her heart. She died later that morning. I felt terrible. My manager checked my notes and told me that they were impeccable. She really was the only support that I ever had.

I had to stop off at my church to pray and when I got home I cried and could not sleep. I pictured everything in my head for days, going over and over like on a perpetual movie reel.

The physicians came in to explain things to the DAY staff. There was no support for the night staff who had actually been there and been a part of it all. The nurse from whom I had received report and who neglected to tell me that the study was on hold, started to back track. She began telling the other staff members that she had told me not to cntinue the study and ultimately went on to inform others in the hospital that I had “killed the patient”.
I understand that there were nurses form other areas in the hospital who had come to our ICU to find out the name of the nurse who had “killed” that patient. There was no support from the physicians or from therapeutic staff in the hospital. I was tramatized.
To make matters worse, I later found a programme in my mail box about the patient’s funeral service! Just when I was feeling like I was taking control again. Certainly, hospitals do very little when we face these types of taumas and yes, I do feel as if I was a perpetrator and not the victim. This has stayed with me over the years and I still feel very apprehensive looking after anyone with pulmonary hypertension.

This document is provided under the terms of a CreativeCommons Attribution Non-commercial Share Alike license. The terms of the license are available at: http://creativecommons.org/licenses/by-nc-sa/3.0/. Attributions are to be made to HealthyDebate.ca, a project under the direction of Dr. Andreas Laupacis, at the Keenan Research Centre, Li Ka Shing Knowledge Institute of St. Michael’s Hospital.